Cocaine Revisited - The American Academy of Insurance Medicine

JOURNAL OF INSURANCE MEDICINE
Copyright Q 2003 Journal of Insurance Medicine
J Insur Med 2003;35:193–195
REVIEW
Cocaine Revisited
David S. Williams, MD, FACP
Insurance companies often test applicants for the presence of cocaine. Because a positive test may automatically preclude further
consideration, such cases often never reach the medical director. The
negative impact of cocaine use on insurability is reviewed.
Address: Ohio National Financial
Services, One Financial Way, Cincinnati, OH 45242.
Correspondent: David S. Williams,
MD, FACP.
Key words: Cocaine, drug testing,
urine testing, life insurance.
C
erance develops with repeated use, increasing
the amount of cocaine needed to produce the
same high. Users often add heroin to IV cocaine (a ‘‘speedball’’), as the effects from direct IV injection of cocaine may be too strong
for most individuals. IV drug abusers in turn
have been found to die at 7 times the rate of
comparable age groups of non-drug users.
Cocaine is metabolized by the liver into benzoylecgonine and ecgonine, which are in turn
excreted in the urine. A single dose of cocaine
can lead to positive urine drug screens for the
next 24–36 hours. When the user also ingests
alcohol, as many do, cocaine is metabolized
into cocaethylene. This metabolite not only
has a longer half-life, but may play a role in
the increased risk of sudden death by users
of alcohol and cocaine. Indeed, in users of
both products, the risk of sudden death is increased 25-fold compared to users of cocaine
only.
Cocaine is one of the most popular and
dangerous illicit drugs used. The National
Household Survey on Drug Abuse (NHSDA)
estimates 1.5 million Americans, 0.7% of the
population older than age 12, are current cocaine users. In the last decade, there was a
ocaine is an alkaloid compound found in
the leaves of a small tree native to the
mountains of northern South America.
Leaves are dissolved in hydrochloric acid to
make cocaine hydrochloride, which can then
be mixed with ether to form freebase cocaine
or extracted with sodium bicarbonate and
water to make crack cocaine. The name
‘‘crack’’ comes from the popping sound this
form of cocaine makes when smoked. Production of crack cocaine is much easier and
cheaper and thus significantly more profitable. A kilogram of cocaine converted to
crack can yield 3 to 8 times the profit of powder cocaine. Smoking either form of cocaine
rapidly yields high blood levels similar to
those achieved with intravenous use. Generally, intranasal cocaine use yields a peak effect in 15–20 minutes and lasts 60–90 minutes, while smoking or injecting cocaine gives
a peak effect in 5–10 minutes and lasts only
30 minutes. Because the user’s ‘‘high’’ depends on the rate of rise and peak blood level,
smoking cocaine produces rapid intense
highs that are quickly followed by ‘‘crashes,’’
promoting frequent use to avoid these profound ‘‘lows,’’ often resulting in binging. Tol193
JOURNAL OF INSURANCE MEDICINE
Table 1. 1999 Annual Poison Control Center Data*
Drug
# of Exposures
# of Deaths
% Deaths/Exposure
4286
1669
1669
1218
5185
1047
40,299
4443
38
305
16,684
1252
1930
465
20,720
4011
70
30
6
10
27
17
65
8
0
2
18
0
0
1
1
1
1.6%
1.8%
—
0.8%
0.5%
1.6%
0.1%
0.2%
—
0.6%
0.1%
—
—
0.2%
—
—
Cocaine
Heroin
Codeine
Morphine
Oxycodone
Methadone
Benzodiazepines
Barbituates
Methaqualone
Chloral hydrate
Amphetamines
LSD
Marijuana
Phencyclidine
Gasoline (inhalant)
Lighter fluid (inhalant)
* Numbers above may underestimate drug usage and deaths, as episodes may go unreported.
Source: Hals et al.1 Reprint permission granted by Thomson American Health Consultants.
37% increase in new cocaine users. This drug
remains the most common cause for drug-related emergency visits, and is the number 1
complaint of patients admitted to drug treatment centers. Alcohol is a well recognized
factor in motor vehicle accidents, with 40%70% of traffic fatalities related to its abuse. Yet
illicit drug use is likewise highly correlated
with traumatic injury and death; indeed, several studies have demonstrated positive illicit
drug screens in 40%-80% of major trauma
victims, with cocaine being the most common
drug of abuse.
but as a result of increased platelet aggregation and thrombus formation leading to myocardial infarction. Cocaine increases workload and demand for oxygen, thereby worsening ischemia, and may have direct myocardial toxicity. Patients with cocaine-associated
myocardial infarction may not benefit from
thrombolytics to the same degree as non-users experiencing myocardial infarction. Repeated cocaine use accelerates atherosclerotic
development, as well as nonatherosclerotic
plaque growth.
Central Nervous System
COCAINE’S IMPACT
Cocaine-induced seizures are usually single and self-limited, may occur up to 12
hours after use, and typically occur in patients with no seizure history. Patients with a
previous history of noncocaine-related seizures can experience repetitive focal motor
seizures, and those using large amounts of
the drug (2–8 grams) may experience status
epilepticus. Cocaine is the most common
cause of drug-associated stroke, and causes
90% of strokes in young adults (3rd and 4th
decades of life). Stroke associated with co-
Cardiovascular System
Cocaine use can cause multiple and sometimes lethal dysrhythmias in the user. Cocaine acts as a type 1a sodium channel blocker, like quinidine or procainamide, and prolongs the QT interval by prolonging action
potential duration. It may also provoke dysrythmias through direct sympathetic stimulation and ischemia due to cocaine-induced
coronary artery vasospasm. Ischemia may result not only via coronary vasoconstriction,
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WILLIAMS—COCAINE
caine use can occur with first-time use or in
chronic users. It may cause subarachnoid
hemorrhage, intracerebral bleed, or ischemic/
embolic stroke. There is also a strong connection with psychiatric diagnoses and cocaine
abuse.
Table 2. Accuracy of Urine Testing
Drug
Time Detectable
After Last Use
Marijuana—Single Use
Marijuana—Chronic Use
Cocaine
Heroin
Codeine
Morphine
Amphetamine
Methamphetamine
Alcohol
Barbituates
Benzodiazepines
Phencyclidine
LSD
MDMA, GHB and Inhalants
Respiratory System
Cocaine use has caused increased asthma
symptoms, pneumothorax, pneumomediastinum, noncardiac pulmonary edema, and pulmonary hemorrhage/infarction. Upper airway burns can occur and lead to acute epiglottitis. A syndrome labeled ‘‘crack lung’’
has been described consisting of fever, dyspnea, hemoptysis, hypoxia, chest pain, infiltrates and sometimes respiratory failure developing 1–12 hours post crack use.
1–7 days
1–4 weeks
1–4 days
1–4 days
1–2 days
1–3 days
8–24 hours
1–2 days
1 day
2–10 days
2–7 days
1–7 days
8 hours
Not detected
Source: Hals et al.2 Reprint permission granted by
Thomson American Health Consultants.
Other
Tables 1 and 2 place cocaine testing and
mortality in the context of other well-known
drugs of abuse.
Acute rhabdomyolysis is a well-known
complication of cocaine abuse and may be
seen in users with no other risk factors (trauma, seizures, hyperthermia, hyper/hypotension, etc); in fact, as many as 30% of such
patients will progress to renal failure. Cocaine may also cause direct renal toxicity. It
has caused bowel injury and infarction
through vasospasm. Cocaine use during
pregnancy is associated with a multitude of
maternal and fetal complications, including
eclampsia, placental abruption, and fetal
death or anomalies.
REFERENCES
1. Hals G, Richardson W. Drugs of Abuse and Their
Complications: Emergency Department Evaluation
and Management: Part 1. Emergency Medicine Reports. 2001;22(12):131–146.
2. Hals G, Richardson W. Drugs of Abuse and Their
Complications: Emergency Department Evaluation
and Management: Part 2. Emergency Medicine Reports. 2001;22(13):147–162.
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